How can community pharmacists be supported to manage skin conditions? A multistage stakeholder research prioritisation exercise

Objective To establish research priorities which will support the development and delivery of community pharmacy initiatives for the management of skin conditions. Design An iterative, multistage stakeholder consultation consisting of online survey, participant workshops and prioritisation meeting. Setting All data collection took place online with participants completing a survey (delivered via the JISC Online Survey platform, between July 2021 and January 2022) and participating in online workshops and meetings (hosted on Microsoft Teams between April and July 2022). Participants 174 community pharmacists and pharmacy staff completed the online survey. 53 participants participated in the exploratory workshops (19 community pharmacists, 4 non-pharmacist members of pharmacy staff and 30 members of the public). 4 healthcare professionals who were unable to attend a workshop participated in a one-to-one interview. 29 participants from the workshops took part in the prioritisation meeting (5 pharmacists/pharmacy staff, 1 other healthcare professional and 23 members of the public). Results Five broad areas of potential research need were identified in the online survey: (1) identifying and diagnosing skin conditions; (2) skin conditions in skin of colour; (3) when to refer skin conditions; (4) disease-specific concerns and (5) product-specific concerns. These were explored and refined in the workshops to establish 10 potential areas for research, which will support pharmacists in managing skin conditions. These were ranked in the prioritisation meeting. Among those prioritised were topics which consider how pharmacists work with other healthcare professionals to identify and manage skin conditions. Conclusions Survey responses and stakeholder workshops all recognised the potential for community pharmacists to play an active role in the management of common skin conditions. Future research may support this in the generation of resources for pharmacists, in encouraging public take-up of pharmacy services, and in evaluating the most effective provision for dealing with skin conditions.


Introduction
The introduction paints skillfully a picture of the importance of community pharmacist's role in primary careespecially after the pandemicincluding minor ailment, and how skin conditions are common in this realm.However, the introduction does not justify the need for establishing the research priorities of the care of skin conditions by community pharmacists after the implementation of minor ailment management by pharmacists.Whyafter the service is approved in several countries including the UK and Canadado we need to establish the research priorities of skin conditions?To evaluate ho these are applied and their impact.
What is known about this subject?Such justification is essential to convince the reader of the importance of the research.Methods -I understand that the survey was submitted for publication but more details about the survey.Please provide briefly details of the PSNC and who were the pharmacists who were targeted with the survey.For example, minimum number of years of practice, practicing in the community with minimum number of hours.
-For the exploratory workshops: what did the "other health care professionals" mean?Please provide details of inclusion criteriaif anyof other health care professionals.-Similarly, were there any inclusion criteria of members of the public to establish their close knowledge and relevant perspective of pharmacists care of skin conditions.
-Were there both quantitative and qualitative questions in the survey?-Were there transcripts of the interview questions of the workshops?-Was there a minimum sample size for each section of the study?-Please define the (PPI collaborators).
-I did not have access to the Supplementary file 1 to see the additional details of the methods.Results -Did the authors exclude any participants who were not eligible?-It seems that only GPs and one speciality nurse were recruited.Were there any other primary care RNs, RPNs, NPs ..etc -I applaud the participants and authors for the audacity using the word "diagnosis" while referring the assessment of skin conditions.I do believe that this is essential for the furtherance of pharmacists' practice.In the jurisdiction where I practice and do research, people are told explicitly to avoid the "D" word in referring to minor ailment management by pharmacists or use the "assess" or "self-diagnosed" phrase.The justification was that pharmacists are not trained to be diagnosticians.I do suggest acknowledging that the use of "diagnose" might not be sanctioned in every jurisdiction.-I suggest using skin conditions among "people of colour" rather than "skin conditions in skin of colour".Discussion -I would suggest adding more context of what is currently being offered in the UK by pharmacists in the skin care in the community currently, and how the identified questions can be use to enhance this provision.
-Although the results in fact reinforce previous knowledge regarding issues like the workload, competency, and resources, I think the discussion can do more justice by highlighting the new knowledge this research yieldedeven if the concepts are already known.For example, the resources of skin conditions among people of color is relatively an issue which was missed for a long time, at least where I workwhere this limitation in textbooks and bulletins targeting pharmacists was identified recently.As such, a stronger language confirming the importance of this new knowledge would be justifiable.
-I suggest disentangling the issue of general public awareness from general public trust in their community pharmacists.In earlier provisionssuch as vaccination-although the first one was found a major barrier impeding larger implementation, the former was found as a non-issue (i.e., members of the public in fact trust their pharmacist).

GENERAL COMMENTS
This paper addresses an interesting topic on the role of community pharmacists in providing dermatologic advice/treatment.In the narrowest sense, this paper ranks potential topics for research, in a broader sense, it discusses some of the associated barriers and concerns from pharmacists and the public.
Personally I felt that the premise for supporting pharmacists taking on a greater role in the care of patients with skin conditions needs to first be established.Should community pharmacists even be providing greater dermatological advice and treatment?Dermatological diagnoses are challenging to make compared to other diseases (even for GPs), as also evident by the pharmacists main concern re: misdiagnosis.So the current manuscript and discussion seems only relevant if we all agree that comment pharmacy should continue to expand and extend provision in the dermatologic setting.
I'm also curious to know what was the rationale for this current study/interview of pharmacists?-If it were to generate research ideas, then is it really necessary to conduct focused group interviews in this systematic way just to derive ideas?-It were to assess for gaps in the literature where further research may be warranted, then why not a scoping or systematic literature review instead?With the current approach, we have to be aware that research topics proposed by interviewees do not necessarily represent gaps in research (e.g.these questions may have already been investigated and published) Another concern is the relatively limited groups of stakeholders.There were only 3 doctors and 2 nurses out of 200+ participants.
To compound the problem, there were no dermatologists nor policy planners/administrators which I personally feel would be important to include.
I think it'll also be good to elaborate more on the methods (e.g.content, thematic and framework analysis) as it is not clearly described or presented.E.g. how did the authors came up with the list of themes and research questions.
In terms of improving the manuscript flow, I personally feel there was heavy focus on each individual research question, many of which were fairly similar and overlapping.This made the results section in page 8-22 quite lengthy.In contrast, stage 1 and 3 were only very briefly mentioned in the results.
I would have also liked to see more discussion on a broader range of topics for example the physician and patient perspective, evaluation of outcomes (whether this improves patient outcomes/healthcare utilisation/patient satisfaction etc), and any current implications for practicing pharmacists or dermatologists.

REVIEWER
Cowdell, Fiona Birmingham City University, Faculty of Health Education and Life Sciences REVIEW RETURNED 02-May-2023

GENERAL COMMENTS
This is a well written manuscript about an important and topical subject.At present it is long and it would benefit from cutting the length / number of quotes to include only those most salient.Much is made of a dedicated resource for community pharmacists and while I understand this, I encourage you to think about how guidance for different professions and for citizens fits together so that we offer coherent and consistent information.

VERSION 1 -AUTHOR RESPONSE
Reviewer 1 I would be interested if any data on the following -pharmacists are often educated to advise people to apply topical steroids sparingly due to fear of adverse effects however many patient with significant atopic dermatitis etc require more liberal application Thank you, I'm afraid this was not a common theme that was discussed within the focus groups.

N/A
Reviewer 2 I found that the issues elicited from participants more of practice issues pertaining to the facilitators and barriers impacting effective implementation rather than research priorities.I would suggest clarifying the language of the themes that they are trying to get a picture of what are the most important issues facing pharmacists currently in this provision, which may trigger the need for research questions (where the third phase f the project prioritized).
Thank you, we explored the barriers and facilitators within this project to inform the research questions where it was difficult to explain the concept of a research question.However, this was unclear, and we have clarified this in the aims within the methods.
"Workshops and interviews were undertaken online using Microsoft Teams and took place between April and July 2022.
They were structured according to stage 1 data, with key themes explored further through group discussion.Discussion focused explicitly upon "research priorities"; although notions such as "barriers", "facilitators" and "challenges" were also used to make discussions less abstract and to support broad participation."[17].Most recently the government announced that a "Pharmacy First" scheme will be introduced within England.Through this scheme pharmacists will be able to prescribe medications (through PGDs) to treat conditions such as impetigo, shingles and infected insect bites [18].In Wales and Scotland, the pharmacy first scheme has already been implemented.In these areas medications can also be provided via PGDs or through independent (nonmedical) prescribers [19].For example, in Scotland there are PGDs available for medications to treat impetigo, shingles and skin infections [20].Therefore, within the UK context pharmacists are already involved in the diagnosis and treatment of skin conditions and this involvement has accelerated in the past few years." I understand that the survey was submitted for publication but more details about the survey.
Please provide briefly details of the PSNC and who were the pharmacists who were targeted with the survey.For example, minimum number of years of practice, practicing in the community with minimum number of hours.
Thank you for asking for clarification of the survey.The survey was opportunistic and there were no specific inclusion criteria i.e. all pharmacists (and other members of pharmacy staff) were eligible to complete the survey.Details of the survey have now been submitted for publication to the journal "Skin health and Disease".Within this publication there is more information regarding the demographics of survey participants.
The PSNC, now known as community pharmacy England, represents community pharmacy contractors to the NHS.
We have added the following text and we will add the reference for the paper relating to the survey as soon as it is published.
"The survey was opportunistic and there were no specific inclusion criteria i.e. all pharmacists (and other members of pharmacy staff) were eligible to complete the survey." For the exploratory workshops: what did the "other health care professionals" mean?Please provide details of inclusion criteriaif anyof other health care professionals.
Thank you for requesting this clarification.
We have added: "other healthcare professionals (e.g.GPs, specialist nurse practitioners)" Similarly, were there any inclusion criteria of members of the public to establish their close knowledge and relevant perspective of pharmacists care of skin conditions.
Thank you for requesting this clarification.
We have added "all members of public who expressed an interest in the project were invited to join focus groups regardless of their experience of skin conditions or pharmacies." Were there both quantitative and qualitative questions in the survey?
Yes the survey included free text and categorical questions.
Were there transcripts of the interview questions of the workshops?
Thank you we have added topic guides as an appendix.
Was there a minimum sample size for each section of the study?
There is no formal sample size for this type of research, rather we sought broad engagement to ensure pertinent insight and discussion.
We aimed to include 18-20 members of pharmacy staff and at least, 8-10 members of the public, 8-10 GPs in phase 2 and equal numbers of participants in phase 3 (approx.10 public and 10 healthcare professionals).We did not manage to recruit these numbers of patients (particularly GPs in phase 2 and pharmacy staff in phase 3) and we acknowledge this in the limitations section of the paper.
Please define the (PPI collaborators).Thank you were have done this.PPI (patient and public involvement) I did not have access to the Supplementary file 1 to see the additional details of the methods.
For editorial team to sort please Did the authors exclude any participants who were not eligible?
No we did not.
It seems that only GPs and one speciality nurse were recruited.Were there any other primary care RNs, RPNs, NPs ..etc No unfortunately we were unable to recruit any other practitioners.
I applaud the participants and authors for the audacity using the word "diagnosis" while referring the assessment of skin conditions.I do believe Thank you for raising this issue.We hope that by adding the text regarding the extent to which U.K. pharmacists are involved in the We have added the following text to the discussion: that this is essential for the furtherance of pharmacists' practice.In the jurisdiction where I practice and do research, people are told explicitly to avoid the "D" word in referring to minor ailment management by pharmacists or use the "assess" or "self-diagnosed" phrase.The justification was that pharmacists are not trained to be diagnosticians.I do suggest acknowledging that the use of "diagnose" might not be sanctioned in every jurisdiction.
treatment of skin conditions clarifies the fact that within the U.K. this is not at all controversial.However, we have also added additional text to the discussion section.
"The term diagnosis in relation to pharmacist-led activity may not be as widely understand across the globe.However, our survey found identifying and diagnosing skin conditions a key area for further research.This research could include the role of the pharmacist is diagnosing conditions compared to simply identifying them" I suggest using skin conditions among "people of colour" rather than "skin conditions in skin of colour".
Thank you for this comment.However, we have used this terminology as per the British Association of Dermatologists website: https://www.bad.org.uk/education-training/skinof-colour-in-dermatology-education/I would suggest adding more context of what is currently being offered in the UK by pharmacists in the skin care in the community currently, and how the identified questions can be use to enhance this provision.

As above As above
Although the results in fact reinforce previous knowledge regarding issues like the workload, competency, and resources, I think the discussion can do more justice by highlighting the new knowledge this research yieldedeven if the concepts are already known.For example, the resources of skin conditions among people of color is relatively an issue which was missed for a long time, at least where I workwhere this limitation in textbooks and bulletins targeting pharmacists was identified recently.As such, a Thank you for this comment.The 10 areas for future research we acknowledge are in some ways were unsurprising.However, in order for the drive towards the management of skin conditions within community pharmacy to be successful, it is crucial that all problematic areas are addressed and so we chose not to focus on just the new information.
stronger language confirming the importance of this new knowledge would be justifiable.
I suggest disentangling the issue of general public awareness from general public trust in their community pharmacists.In earlier provisionssuch as vaccination-although the first one was found a major barrier impeding larger implementation, the former was found as a nonissue (i.e., members of the public in fact trust their pharmacist).
Thank you.In the focus groups the public consistently reported that they were not sure that pharmacists had the necessary skills to diagnose and manage skin conditions.This was because they did not know what training pharmacists had received and they were aware of complexities of diagnosing a skin condition.In contrast they also described that they trusted pharmacists to know about medicines as they understood this is what they had spent time studying.Therefore, we think it is still sensible to include confidence in pharmacists as an area for future research.

Reviewer 3
Personally I felt that the premise for supporting pharmacists taking on a greater role in the care of patients with skin conditions needs to first be established.Should community pharmacists even be providing greater dermatological advice and treatment?Dermatological diagnoses are challenging to make compared to other diseases (even for GPs), as also evident by the pharmacists main concern re: misdiagnosis.So the current manuscript and discussion seems only relevant if we all agree that comment pharmacy should continue to expand and extend provision in the dermatologic setting.

As above
As above I'm also curious to know what was the rationale for this current study/interview of pharmacists?-If it were to generate research ideas, then is it really necessary to conduct focused group interviews in this systematic way just to derive ideas?-It were to assess for gaps in the literature where further research may be warranted, then why not a scoping or systematic literature review instead?With the current approach, we have to be aware that research topics proposed by interviewees do not necessarily represent gaps in research (e.g.these questions may have already been investigated and published) Thank you.
This study broadly followed the James Lind methodology for research prioritisation, which stresses the importance of different methods in research question generation.The JLA process also reminds us of the importance of all stakeholder voices being given an opportunity to inform the process.
We recognise, indeed argue, that a systematic review of current initiatives is an important next step.
Another concern is the relatively limited groups of stakeholders.There were only 3 doctors and 2 nurses out of 200+ participants.To compound the problem, there were no dermatologists nor policy planners/administrators which I personally feel would be important to include.
Thank you for raising this issue.Unfortunately, we had difficulties in recruiting GPs to the study.However, two members of the author team are GPs and we hope this would mean that we did not exclude the GP perspective.Although it would have been useful to speak to other stakeholders, this wasn't possible within the scope of the project.However, we still feel there is value in reporting the problems that pharmacists and pharmacy staff commonly encounter.We have included a recommendation in the discussion regarding Added "other stakeholders" to the discussion.
further work to include the views of these other stakeholders.
I think it'll also be good to elaborate more on the methods (e.g.content, thematic and framework analysis) as it is not clearly described or presented.E.g. how did the authors came up with the list of themes and research questions.
We provided a supplementary file which explained how we used content analysis to develop themes from the survey responses.
Were you able to see this file (other reviewers said they could not view supplementary information)?
In terms of improving the manuscript flow, I personally feel there was heavy focus on each individual research question, many of which were fairly similar and overlapping.This made the results section in page 8-22 quite lengthy.In contrast, stage 1 and 3 were only very briefly mentioned in the results.
Thank you we have significantly edited the paper (please see track changed document) I would have also liked to see more discussion on a broader range of topics for example the physician and patient perspective, evaluation of outcomes (whether this improves patient outcomes/healthcare utilisation/patient satisfaction etc), and any current implications for practicing pharmacists or dermatologists.
Thanks-you for your comment.
Such discussion would perhaps be interesting, but is in our opinion beyond the scope of our research prioritisation exercise.
Reviewer 4 At present it is long and it would benefit from cutting the length / number of quotes to include only those most salient.
Thank you we have significantly edited the paper (please see track changed document) Much is made of a dedicated resource for community pharmacists and while I understand this, I encourage you to think about how guidance for different professions and for citizens fits together so that we offer coherent and consistent information.
Thank you, we hope that this issue could be addressed by the question "How can community pharmacists work most effectively with other healthcare professionals in the identification and management of skin disease?"We have also added some text to address the concerns raised by your comment.
The following text has been added: "We would also encourage researchers to consider how resources directed towards community pharmacists can deliver consistent messages to other health care professionals." with disease identification should not/does not equate to research question of "would dedicated resources improve the identification of skin conditions…" 3. Additionally as earlier mentioned, it is important to recognise that these proposed priorities do not necessarily represent true gaps in literature (e.g.there is probably already research evidence showing that education/training/resources does improve identification of skin disease) I was also unable to find the section on having obtained ethics approval and written patient consent (or otherwise approved by the ethics board).

16
VERSION 2 -AUTHOR RESPONSE Reviewer 3 I do feel that they need to be better stated in the limitations section.

Lack of doctors, absence of dermatologists, decision makers
Thank you we have added a note to this effect.
Overall, we were only able to recruit 3 GPs and one specialist dermatology nurse to take part in interviews.We did not include dermatologists or decision makers in the project, reflecting our primary care focus.
2. That research priorities may not be understood by participants, who instead reported on barriers and physical challenges.Challenges and difficulties highlight areas for correction/intervention, and that is quite different from areas for further research.For example, pharmacists highlighting difficulties with disease identification should not/does not equate to research question of "would dedicated resources improve the identification of skin conditions…" Thank you we have added a note to this effect.
We might also acknowledge that the qualitative nature of much of the data generated here necessarily required interpreting as part of data analysisit may be that in our interpretations we found questions and uncertainties that were not intended by participants.The iterative nature of the study with a final workshop specifically focused upon research uncertainties hopefully tempers this process.
3. Additionally as earlier mentioned, it is important to recognise that these proposed priorities do not necessarily represent true gaps in literature (e.g.there is probably already research evidence showing that education/training/resources does improve identification of skin disease) Thank you we have added a note to this effect.
It is important to note that though we have highlighted these questions for future research, we have not conducted a systematic review to check whether there is already research that addresses these issues.
I was also unable to find the section on having obtained ethics approval and written patient consent (or otherwise approved by the ethics board).
Thank you we have clarified the ethical process as described above.
AS ABOVE understand the authors' approach and intentions in terms of participant selection.
resources available, and which might provide sufficient breadth of contribution and insight.